Análisis y seguimiento de proyectos de gran porte

Barts Health NHS Trust also uses Cerner Millennium; in 2013-14 a benefits ‘deep dive’ was undertaken as a joint piece of work between Barts Health and HSCIC. The approach used at

Oxford has incorporated the successes and learning from that work, with the key findings from the Barts study reproduced here for comparison. At Barts, significant benefits were realised as a result of going ‘paperlite’ in their Emergency Department, other findings at Barts Health are summarised in table 8.2.2.

Figure 8.2.2: Key findings from the Benefits ‘deep dive’ at Barts Health NHS Trust 2013 – 2014

• Key findings from the Barts ‘deep dive’:

• Elsewhere in the trust there are numerous ‘pockets’ of success, notably in the use of the system as a clinical tool but adoption is not widespread

• The success of pioneering users will be limited until there is more universal adoption of the system at which point the majority of the value from the investment can be realised

• There are significant inefficiencies and pitfalls of parallel running paper based processes alongside an electronic data system

• Senior clinical leadership and commitment to the system’s use has been an essential ingredient in the areas where success has been observed

• The main barriers to widespread adoption are the system’s performance issues and the need for a greater focus on business change, particularly continuous system training for staff

Several of these findings have been replicated at OUH; notably in that ‘pockets’ of enthusiasm are ripe for spread to other areas as part of the process of continuing implementation, and that the success and value of the whole system depends on universal adoption across all clinical and administrative processes. This in turn will eventually enable the trust to stop using paper records. Similarly to the findings at Barts, OUH has experienced system performance issues, and there is still a need for ongoing training and support for staff to avoid any poor practice creeping in.

8.3.

Clinical Digital Maturity Index

In November 2013, EHI Intelligence published the baseline Clinical Digital Maturity Index (CDMI), the first benchmark of the relative digital maturity of all English NHS acute trusts. Based on the EHI Intelligence Database, the CDMI captures the presence (rather than extent of implementation and use), of key administrative and clinical systems in acute trusts, and so provides a unique resource for analysing their digital maturity at a national, regional, trust and system level.

The e-Health Insider Intelligence Clinical Digital Maturity Index (CDMI+12) report tracked progress against the 2013 baseline, and provided the first, comprehensive, longitudinal measure of NHS progress on digitisation over a 12 month period. Information is clustered into 9 levels. OUH was ranked overall 7th in November 2013 with a score of 88; in September 2014 the rank had

increased to joint 5th with a score of 90. This placed OUH into the highest rank of all the trusts with Cerner Millennium under the BT LSP contract. In April 2015, OUH improved again, reaching the top of the CDMI rankings, following completion of the seven stage roll-out of e-prescribing across all the directorates and the implementation of iNET in Neuro ICU:

http://www.ehi.co.uk/news/EHI/9989/oxford-hits-height-in-digital-maturity

Figure 8.3.1: EPR programme update to OUH Board April 2014

‘The Integrated Business Plan and supporting IM&T Strategy establish an ambitious goal to

establish a digital hospital, developing a culture that exploits digital technology to improve care and work more efficiently. EPR is fundamental to this. We have made good progress in the past 3 years in moving away from a legacy Patient Administration System, upgrading our digital imaging system and building up our infrastructure. Recently the Trust was scored 7th (*subsequently 5th in September 2014, and 1st in April 2015) in the HSCIC sponsored Clinical Digital Maturity Index which ranks all English NHS Trusts on the maturity and efficacy of their clinical IT systems; once the Trust has completed the implementation of electronic prescribing the expectation is that we would be in the top 3 across the UK. As a Trust we will need to increase our investment in IM&T and EPR infrastructure in order to deliver the vision.’

EPR programme update to Trust Board April 2014 (*with updates)

8.4.

Health Information and Management Systems Society

(HIMSS) analytics

Overall progress with the Cerner Millennium EPR at OUH suggests an opportunity for OUH to plan for HIMSS accreditation in future; in order to benchmark within the digitally leading edge healthcare providers in Europe, and fully recognising the level of adoption of the systems in use.

HIMSS Europe, part of HIMSS5, recognises hospitals for improvement in their delivery of healthcare through the use of information technology and electronic management systems. It grades hospitals using the European Electronic Medical Record Adoption Model (EMRAM), with ratings running from 0 to 7. Grading criteria are strict, with an active accreditation process. Those organisations that demonstrate effective electronic systems for specific functions such as patient records and medicines management achieve a high grade.

Figure 8.4.1: HIMSS analytics Europe – summary of European EMR adoption model

European EMR adoption model SM © 2012 HIMSS Analytics Europe Stages Cumulative capabilities

Stage 7 Complete EMR; CCD transactions to share data. Data warehouse feeding outcomes reports, quality assurance and business intelligence. Data continuity with ED,

ambulatory, OP

Stage 6 Physician documentation interaction with a full CDSS (structured templates related to clinical trigger variance and compliance alerts) and closed loop medication

administration

Stage 5 Full complement of PACS displaces all film-based reporting

Stage 4 CPOE in at least one clinical service area and/or for medication (i.e. e-Prescribing); may have Clinical Decision Support based on clinical protocols.

Stage 3 Nursing / clinical documentation (flow sheets); may have Clinical Decision Support for error checking during order entry and /or PACS available outside Radiology

Stage 2 Clinical data repository / Electronic Patient Record; may have controlled medical

vocabulary, clinical decision support (CDS) for rudimentary conflict checking. Document imaging and health information exchange (HIE) capability

5

HIMSS is a global, cause-based, not-for-profit organization focused on better health through information technology (IT). HIMSS leads efforts to optimize health engagements and care outcomes using information technology.

Stage 1 Ancillaries – Lab, Radiology, Pharmacy – all installed or processing LIS, RIS, PHIS data output online from external service providers

Stage 0 All three ancillaries (LIS, RIS, PHIS) not installed or not processing Lab, radiology, Pharmacy data output online from external service providers

As an example for comparison, Croydon Health Services NHS Trust was awarded a ‘Grade 6’ rating; the first in the UK to achieve this level, (no UK Trusts currently hold a Grade 7). Croydon also uses the Cerner Millennium Electronic Medical Record, which was implemented in September 2013 through a local supplier provider contract with BT and managed by the HSCIC.

9. Conclusions

Using the originally intended business case capabilities and benefits as a framework, the following is a summary of achievements to date. All but one of the capabilities planned in the LSP and trust business cases have been delivered; and a critical mass of adoption achieved which is beginning to yield evidenced benefits.

• Replacement of obsolete and/or expensive to maintain legacy systems – in place.

• Full compliance with programmes such as Choose and Book Direct Booking (the Greenfields are some of the last trusts in the country yet to achieve Direct Booking), and enabling use of NHS number – patient choice in place; fully achieved; directly bookable clinics are available

throughout the trust.

• Delivery of the foundations for a solid information technology platform in preparation for the Foundation Status – foundations are in place and being built on.

• Provision of a modern system which can deliver a single patient record, supporting clinical decision making – foundations are in place; a single record can be delivered in future. • Reduction in the risk of errors arising from having multiple systems by consolidating

information in one place and reporting – foundations are in place; integration of several

clinical systems within the trust will reduce duplication at the interfaces.

• Clinical Notes will be contained in one solution, enabling a single point of identification for all systems, and available at any point of access – foundations are in place; complete clinical

data within the electronic record will be required before reliance on paper records can be eliminated.

• The ability to record and access patient allergy and alert information electronically at appropriate points in the patient journey – in place and use has increased.

• Improved audit trail facilities from both a clinical and information governance perspective – in place; additional structured clinical data recording within EPR is required to fully deliver the benefits associated with clinical audit.

In addition, there are benefits associated with efficiency and effectiveness such as:

• Bed management – not yet fully in place; there is a dependency on real time admission and discharge (ADT) data which is at least partly being driven by ePMA roll out. Figures indicate a recent improvement in the timeliness of ADT recording.

• Discharge Summary which sends a message to Pharmacy to dispense drugs – the electronic discharge summary to GP and ePMA TTO processes are both in place; note that the

There is potential to realise efficiencies in clinical decision making associated with length of stay, clinic utilisation etc. Length of stay efficiencies result from a range of transformation and

improvement initiatives across OUH and within the health community, and are very difficult to attribute accurately (benefits mapping would help with this). Some process time reductions within the TTO dispensing process have been demonstrated which are expected to contribute to more patients going ‘home before lunch’; a repeat of this audit following further stages of the ePMA roll- out will be undertaken by pharmacy.

The findings that are intended to support future developments (after exit from the BT LSP contract and transition to a locally contracted instance of Cerner Millennium) are outlined here.

• Staff across OUH are keen to increase the momentum of deployment. Overwhelmingly

comments were made such as ‘everybody should be doing it; everything should be on there’; although it is recognised that capacity for business change and adoption limits the possible speed of implementing a full clinical EPR.

• Roll-out of ePMA is clearly a ‘tipping point’. While safety and reliability improvements and

‘released time to care’ benefits have been demonstrated, these are still to be fully realised as the system is yet to be fully used for the entire clinical record.

• The most significant problem encountered was the resource, time and effort being used on patient pathway validation for the 18 weeks referral to treatment pathway. Initial difficulties with a solution not designed for the UK waiting list management requirements led to a high level of 'system' workarounds. This suggests that a robust 'system fix ' with workflow redesign and process improvements are needed to resolve the problem.

• Notable practice was observed in maternity for safeguarding, for audit and in

demonstrating how data can be used to plan service development.

• Numerous other clinical systems which already provide value are in use, including CareView, SEND, SafeTX, Blue Spier etc. Any opportunities for integration would add value to both these clinical systems and EPR, for example integrating SEND with EPR was identified as a desired improvement by Neuro ITU nurses, and the process safety provided to blood products transfusion is recognised by all staff using SafeTX, but currently requires a little duplication. • Training / coaching / support / embedding change takes significant and ongoing

leadership, coaching and direction, and is supported by the floor walkers at implementation

of each module. Feedback from the areas observed indicated that more follow up training would help staff to get the best from EPR.

• Connectivity for peripatetic services (midwifery) – whatever solution is taken forward will

provide useful lessons and insight for other peripatetic services in future.

• A recent improvement to the CIP approach and governance, driven by Blood products

exemplar suggests a notable shift towards benefits thinking, value and the need for return on investment. Priorities are now being set by divisions and services rather than the IT teams. • It has proved difficult on occasions to access and use existing trust held data which has

limited some of the context and baseline analysis opportunities.

• There is potential to strengthen the approach to the use of data for example by

developing a broader understanding of variation in processes; illustration throughout this case study is intended to support this.

Discussions on the need to use incidents data has resulted in additional reporting by ePMA roll out phase and can be used to evidence benefits realised if tracked and analysed with benefits enabled by EPR in mind for example:

• Medications incidents and harms • Record keeping / communication

Reporting and analysis of medications incidents in the medical division has now been aligned with reporting into the medications subgroup.

Work in partnership with OUH to value the efficiency benefits continues.

10.

Recommendations

Overall recommendations are made in response to the specific observations and findings at OUH and are intended for the trust to use in the context of existing plans to optimise the EPR and other technology.

As with the Barts Health ‘deep dive in 2013, the report is intended to be publically available and used by other organisations implementing an electronic care record. While local contexts are inevitably (at least partly) different, some common challenges are evident in many healthcare provider organisations and health communities.

The following recommendations align with the trust’s strategic objectives (seen in section 3.2).

Recommendation 1: The recent increase in use and adoption is related to the ePMA roll-out;